Provider Demographics
NPI:1962513143
Name:BARRADAS, MARK ANTHONY (DDS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:BARRADAS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 MISSION RD
Mailing Address - Street 2:SUITE #101
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-1393
Mailing Address - Country:US
Mailing Address - Phone:650-589-4600
Mailing Address - Fax:650-589-4602
Practice Address - Street 1:1135 MISSION RD
Practice Address - Street 2:SUITE #101
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-1393
Practice Address - Country:US
Practice Address - Phone:650-589-4600
Practice Address - Fax:650-589-4602
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34667122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB 34667-01OtherDENTICAL